Be sure to listen to the latest Episode 463 with Betsy Seals from 2025.
Medicare Advantage (MA) enrollment has nearly doubled over the past decade. It grew 37% from 2016 to 2020. Right now, MA comprises nearly 40% of the Medicare population—and that number is only expected to grow.
So, in case you’ve been out of the loop, at the beginning of 2020, CMS (Centers for Medicare & Medicaid Services) rolled out a third category of these “chronic supplemental benefits.” And these chronic supplemental benefits allow plans to offer basically services to attenuate social determinants of health to offer stuff like nonemergency transportation, meals, home modifications … that whole list.
This is all, really, part of a broader bipartisan effort to move Medicare from an acute care to a chronic care program. Then … corona.
So, the question I’m kind of wondering about at this juncture is, Were/Are MA beneficiaries able to maintain their health status better than, say, other plan designs, especially given some of these chronic supplemental benefits, which you’d think would be super helpful in the middle of a pandemic?
This should make sense, and it should really be true. At its core, MA is, as John Gorman put it when he was on the show last year, the biggest value-based payment experiment in the universe. And patient outcomes have definitely improved for MA patients over traditional FFS (fee for service), especially in the south and in other areas rife with cardiovascular and metabolic disease. So, that sounds great.
Now let’s talk about the cash money denominator in the value equation. Humana reported $1.8 billion in profit for the second quarter. That was nearly double its haul in Q2 2019. So far, 2020 has seen a profit that is a 94.5% increase year over year. Humana’s earnings are not an outlier. MA plans across the board did very well, thank you very much, in the middle of a pandemic.
Given that MA hasn’t actually reduced PMPM (per member per month) costs last time I looked at it, you’d think and hope that the confluence of higher rates and less restrictions on extra benefits should definitely lead to greater scrutiny on the plans by CMS. We’ll see what happens.
Anyway, it occurred to me that it might be interesting to get a bead on what MA plans themselves have been contemplating and thinking about relative to the supplemental benefits et cetera. In this health care podcast, I speak with Betsy Seals, cofounder of the Rebellis Group. Betsy spent many years working with and for Medicare Advantage plans. I thought Betsy would be the perfect person to talk to to get a bead on what’s happening on the MA front right now.
You can learn more at rebellisgroup.com.
Betsy Seals is a cofounder and chief operating officer at Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage organizations and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 18 years of experience.
Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the Medicare landscape. Betsy’s expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that addresses social determinants of health, and health plan operations.
Betsy got her start in managed care on the health plan side, where she held roles in compliance and operations. Betsy also spent many years as a managed care compliance and operations consultant with Gorman Health Group, where she exited as chief consulting officer in the fall of 2018.
03:45 What is a Medicare Advantage plan?
04:02 The core imperatives for leaders of Medicare Advantage plans.
04:31 “How is risk adjustment functioning?”
04:34 Making disenrollment rates and member complaints top of mind for MA leaders.
05:40 “We all want to know why members are leaving. Well, they’re telling you!”
05:50 Star rating measures.
07:33 “Will Medicare beneficiaries really have confidence … going into the doctor’s office … next year?”
09:11 “Now, it’s not just ‘Is your doctor in the network?’ It’s ‘Does your plan also offer telehealth?’”
12:13 “When you really look at Medicare beneficiaries aging into the program or … younger … beneficiaries, their shopping trends and their consumer expectations are very much the same as yours and mine.”
13:58 CMS’s adjustment in April that allows MA plans to make changes to their benefits midyear to provide to beneficiaries’ changing needs during the pandemic.
16:01 Supplemental benefits as a decision-making factor in enrollees’ Medicare Advantage plan selection.
16:28 “The decisions made during this time with how to increase benefits or how to address the issues going on with your membership will have a really great impact on [your] AEP [annual enrollment period].”
18:12 “I think that there’s a real lack of understanding … around what issues are impacting their actual membership … but really understanding the demographics and the social determinants of health that are impacting your local landscape.”
19:30 “Health care’s not always related to in-office doctor visits.”
19:40 “I really do think that CMS is headed … to understanding that federal dollars for the Medicare program should not just be spent on doctor’s visits or screenings.”
21:10 “I think that there’s been a real shift in … what we understand now and also what we’re able to predict.”
23:24 Where Medicare Advantage plans fall in addressing population health management, working with hospital organizations, and social determinants of health.
24:24 Betsy’s advice for providers dealing with MA plans.
24:46 “I … think that this is … a missed opportunity [for] provider and plan partnership in a lot of ways.”
26:07 “Really understanding that the market has shifted and the way the beneficiaries enroll this year is going to be very different than it ever has been before.”
29:25 “One thing that shouldn’t be overlooked is that we really have an opportunity to dig into the data.”